Word Document Version:  4CR Membership Application Form.docx

 

Campus/Community Consortium of

the Capital Region (4CR)

Membership Application Form

 

 

The Campus/Community Consortium of the Capital Region (4CR) is an academic service learning (ASL) network which aims to create and sustain strong community partnerships, integrate ASL pedagogy in the classroom and community, and work on community development.  4CR is committed to deep service, student growth and strong community relationships.  4CR is a membership organization of educational institutions, faculty members, students, and Community Partners.

 

4CR defines academic service learning as a pedagogy in which students are fully engaged in their community and meet course or program learning objectives by working collaboratively with community organizations.  Academic service learning is equally beneficial and rewarding for all students, faculty and community partners.

 

Benefits of being a 4CR member include:

·         Access to trainings, workshops, conferences and other educational topics connected with academic service learning;

·         Connect with a network of multiple local community partners, higher education institutions, K-12 schools, and students who share a commitment to partnering and collaborating;

·         Access website resources which include course syllabi, faculty profiles, community partner profiles, calendar of events as well as regional and national resources

·         Receive network updates on upcoming events, opportunities, etc.

·         Project and logistical support assistance

 

The membership fee is based on the size of your institution.  The ASL Steering Committee will work with each institution to the determine the appropriate membership fee.

 

Date:  ________________________________________________________________________

 

Name of Applicant:  _____________________________________________________________

 

Name of Institution/School/Community Partner:  ____________________________________

 

______________________________________________________________________________

 

Primary Contact Person for 4CR:  __________________________________________________

 

Address:  ______________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Phone:  _______________________________________________________________________

 

E-mail:  _______________________________________________________________________

 

Fax:  __________________________________________________________________________

 

 

 

Please check the box which best represents your institution:

 

        College/University                                 K-12 School                            Community Partner*           

 

*A Community Partner is any Not-for-Profit organization, municipality, or any other government entity (e.g., YWCA or the Town of Colonie)

 

What is the mission of your institution?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

How does Academic Service Learning fit into that your mission?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

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What population(s) do you serve?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

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What types of services and programs does your institution provide?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

Is Academic Service Learning currently being utilized at your organization/institution?  If so, how?  Who are your partners?

 

______________________________________________________________________________

 

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Why do you wish to become a member of the 4CR network?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

 

Would you be willing to host workshops, trainings or other network events at your site?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

Thank you for completing the 4CR Membership Application Form!

 

Please return this application mail or e-mail to:

Lauren Johnson

Academic Service Learning Coordinator

Siena College VISTA Fellows Program

Hines Hall 103

515 Loudon Rd

Loudonville, NY 12211

ljohnson@siena.edu

 

Mathew Johnson

Campus/Community Consortium of the Capital Region

Siena College

515 Loudon Road

Loudonville, NY 12211

 

E-mail:  4CRASL@gmail.com 

Please include “4CR Member Application” in the e-mail Subject line.

 

Phone:  (518) 782-6944

 

Wiki:  http://4crsl.pbworks.com

 

 

Please print out the application above, complete it and mail it in or download the following file (4CR Membership Application Form.docx), complete the application and e-mail it to 4CR at 4CRASL@gmail.com.